This policy identifies when UnitedHealthcare will separately reimburse physicians or other qualified health care professionals for Prolonged Services when reported in conjunction with companion Evaluation & Management (E/M) codes or other services.
In accordance with The Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA), Prolonged Services without Direct Patient Contact (CPT codes 99358-99359) will not be separately reimbursed when reported with Care Management (CM) CPT codes 99484, 99487, 99489, 99490, 99492-99494, G2058 and Transitional Care Management (TCM) CPT codes 99495 and 99496.
For the purpose of this policy, the Same Individual Physician or Other Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.
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Q: Do Prolonged Services with Direct Patient Contact include patient time spent with office staff and/or patient time spent unaccompanied in the office?
A: No. The Prolonged Services with Direct Patient Contact must be between the patient and the physician or other qualified health care professional who provided the initial service. Office staff includes anyone who is not the primary provider of the service. The time a patient remains unaccompanied by the primary provider also cannot be counted.
Q: Is time spent waiting for test results or for potential changes in a patient's condition reported as prolonged services?
A: Per CMS, time spent waiting for test results or for changes in the patient's condition cannot be reported as prolonged services.
Q: Should a physician or other qualified health care professional report prolonged services with preventive medicine E/M codes (CPT codes 99381-99397)?
A: No. Preventive medicine codes are not time-based codes; therefore, prolonged services are not separately reimbursed.
Q: May a physician or other qualified health care professional report prolonged services (CPT codes 99354-99357) with modifier 25 when a significant and separately identifiable E/M service is performed along with a separate service or procedure?
A: According to CPT, modifier 25 may be appended to prolonged services codes if there is adequate supporting documentation that describes the service provided and indicates the service is significant and separately identifiable from another service or procedure on the same date of service.